跟外侧动脉穿支皮瓣的应用解剖

目的　探讨跟腱区及跟部皮肤软组织的血供解剖学,为跟外侧动脉穿支皮瓣的临床应用提供解剖学基础。 方法　16侧经红色乳胶灌注的成人下肢标本,解剖观察跟外侧动脉“垂直段”及其穿支血管的位置、口径、数目及分布规律。 结果　位于小腿后骨筋膜鞘深部的腓动脉于外踝尖上(6.6±1.1) cm ( 5.5~9.4 cm) 发出腓动脉前穿支和跟外侧动脉,跟外侧动脉下行穿出分隔小腿后骨筋膜鞘浅、深部之小腿后筋膜隔到达外踝后间隙,于腓骨肌腱与跟腱之间移行,继续绕外踝向前下方分布。小腿下段腓动脉、跟外侧动脉穿支数为(3.6±0.7)支,口径为（0.9±0.29） mm,营养跟腱区及跟部皮肤软组织。 结论　研究结果显示跟腱区及跟部皮肤软组织的血供主要来源于腓动脉、跟外侧动脉,为跟外侧动脉的命名、临床应用以及小腿中下段皮瓣的设计和跟部手术提供解剖学基础。     

带血管蒂跟骨瓣转位修复距骨骨折的应用解剖

在解剖观察30侧成人足标本时,观察到跟外侧动脉恒定地分支分布到跟骨体外侧,滋养动脉有7.5(6～12)支,外径为0.5mm。跗外侧动脉、腓动脉穿支的降支和外踝前动脉亦以肌骨支分布于跟骨前外侧端,上述动脉之间有恒定的吻合。根据跟骨外侧血管分布的解剖学规律性,设计了外侧骨瓣转位修复距骨颈骨折、关节植骨融合术,经临床应用证实,取踝后外侧入路,可任意选择上述血管之一为蒂的跟骨瓣。文中讨论了骨瓣设计,骨瓣截取的应用解剖要点。     

距跟外侧韧带的解剖学研究及其临床意义

目的 观察距跟外侧韧带(LTCL)的解剖学特征并分型,为踝关节外侧面损伤的诊治提供解剖学依据.方法 取50例(左侧40例,右侧10例)结构完整的成人下肢标本,解剖踝关节外侧的LTCL、跟腓韧带(CFL),测量LTCL、CFL的长度及宽度,观察二者的关系,对LTCL划分解剖学类型.结果 有12例标本出现LTCL,该韧带具有如下解剖学类型:①LTCL从CFL分出5例(10％),LTCL向前上方连于距骨或距腓前韧带的前下缘;②LTCL具有独立的起点4例(8％),此LTCL与CFL纤维方向几乎平行,向前上方连于距腓前韧带的下缘;③LTCL与CFL具有共同的起点3例(6％),但二者均为独立的韧带;④LTCL缺如38例(76％).LTCL与CFL的宽度相比,差异有统计学意义(t=2.255,P=0.032).结论 对LTCL的解剖学分型,不仅是对既往研究的补充,也为踝关节外侧面损伤的影像学诊断及外科治疗提供基础支持.     

跟外侧动脉的解剖学研究

目的 解剖观察跟骨外侧皮肤的血供,了解跟外侧动脉的影响.方法 人体下肢常规防腐动脉内红色乳胶灌注标本解剖观察跟骨外侧动脉的来源、走行、分布和吻合.结果 跟外侧动脉在外踝尖上方12～34mm处来自腓动脉发出,向后下方迂曲走形,在跟骨结节水平距跟腱前缘距离6～15mm,转而向下方,与足底垂直走形,在足后跟转而向前,通向第五跖骨基底.跟外侧动脉在外踝尖后下方和下方沿跟骨外侧壁迂曲行进,发出分支支配跟外侧皮肤血运,到第V跖骨基底附近与跗外侧动脉形成血管网.结论 跟外侧动脉在跟骨外侧位置恒定,主干清晰,是支配跟骨外侧皮肤血运的主要动脉.     

小腿前外侧和足背外侧岛状皮瓣的应用解剖

目的:为临床施行经小腿骨间膜前方游离腓动、静脉的小腿前外侧岛状皮瓣和足背外侧岛状皮瓣转位术提供解剖基础。方法:用46侧成尸下肢标本动脉灌注红色乳胶,观测腓动脉穿支及其外径,外踝前动脉弓和足背外侧动脉弓的外径及其皮支。结果:腓动脉下1/3段紧贴小腿骨间膜后方走行,发出2～5支穿支营养小腿前外侧皮肤,动脉外径(1.2±0.4)mm,穿支之间相距10～20mm不等。外踝前动脉弓外径(1.3±0.5)mm,两条伴行静脉外径分别为(1.7±0.5)mm和(1.3±0.4)mm。足背外侧动脉弓外径(1.1±0.5)mm,两条伴行静脉外径分别为(1.3±0.5)mm和(1.1±0.4)mm,发出皮支营养足背外侧皮肤。皮瓣切取范围为小腿外侧和足背外侧。结论:经小腿骨间膜前方游离腓动脉及其穿支与外踝前动脉和跗外侧动脉吻合形成的小腿前外侧和足背外侧串联岛状皮瓣,增加了血管蒂的长度,扩大了皮瓣的切取面积,增加了临床应用的灵活性。     

以腓动脉皮支为蒂小腿外侧皮瓣修复软组织缺损

目的：报道以带腓动脉皮支为蒂小腿外侧皮瓣修复小腿及足部软组织缺损的于术方法。方法：1994年5月至2004年7月，采用以腓动脉皮支为蒂的小腿外侧皮瓣修复小腿、踝部软组织缺损32例．进行回础性分析，总结该手术方法的手术要点。结果：本组32例皮瓣全部成活，其中3例受区为骨髓炎溃疡创面，皮瓣远端边缘有1．0～1．5cm范围坏死，经换药伤口愈合。结论：以腓动脉皮支为蒂的小腿外侧皮瓣修复邻近部位软组织缺损，具有手术创伤较小，时间短，成功率高等优点，是一种安全有效的手术方法。     

跗外侧动脉分支为蒂的足外侧皮瓣解剖及临床应用

目的：为临床上足部软组织缺损的修复提供一种新的术式。方法：４０侧动脉内灌注红色乳胶的成人足标本，解剖观测跗外侧动脉的走行、分支、分布及其远端吻合情况。在解剖学研究基础上，设计跗外侧动脉足外侧逆行皮瓣移位术。结果：①跗外侧动脉由足背动脉发出，其体表投影线相当于踝间连线下２．６±１．１ｃｍ足背动脉搏动点至第５跖骨底连线。动脉起始处有一外径０．５±０．２ｍｍ、长１．０±０．２ｍｍ的皮支较恒定，终支形成前行支和后行支，分别向前、后行与弓状动脉、跟外侧动脉相吻合；②经临床应用６例，皮瓣全部成活。创面Ⅰ期愈合５例，经短期换药愈合１例。结论：以跗外侧血管终支之一（前行支或后行支）为蒂可形成足外侧逆行皮瓣，转位修复足跟、外踝及足背远侧皮肤缺损。     

吻合膝上外侧血管髂胫束移植修复跟腱缺损的应用解剖

目的 :为带血供髂胫束移植修复跟腱缺损新术式提供解剖学基础。方法 :在 40侧经动脉灌注红色乳胶的成人下肢标本上 ,对膝上外侧动脉的起源、走行、分支、分布、吻合以及髂胫束的血供来源等进行解剖观测。结果 :膝上外侧动脉于腓骨头上缘近侧垂直距离 5 .2± 0 .9cm处起自动脉 ,起始外径1.8± 0 .4mm ,向外上蜿蜒走行 3 .0± 0 .2cm ,分为升、降支。升支起始外径 1.2± 0 .4mm ,发出肌支和髂胫束穿支 ;降支起始外径 1.2± 0 .4mm ,发出肌支、3～ 5支股骨外侧髁骨膜支及髂胫束穿支。其中低位髂胫束穿支距腓骨头上缘距离 6.1± 1.1cm ,膝上外侧血管髂胫束瓣蒂长 4.9± 1.0cm。结论 :根据膝上外侧血管的分支、分布特点 ,设计吻合血管髂胫束游离移植修复跟腱缺损的术式具有可行性。     

跟腱血供的显微外科解剖及其临床意义

目的：研究跟腱血供的显微外科解剖,为跟腱手术提供参考数据。方法：采用新鲜及下肢固定的标本各１５例,注射红色乳胶,用体视显微镜观测。结果：跟腱血供来自胫后动脉和腓动脉,其分支为跟腱深动脉,内侧动脉、外侧动脉及跟内,外侧支。结论：跟腱深动脉为跟腱的主要营养血管,另在跟腱的内,外侧及下端分别形成动脉网。跟腱的外膜内尚有丰富的膜内动脉网。     

足背外侧动脉链岛状皮瓣的应用解剖

目的　探讨足背外侧动脉链的组成,为施行足背外侧动脉链岛状皮瓣手术提供解剖依据。 方法　用48侧成尸足,解剖观测外踝后动脉跟外侧支、外踝前动脉降支、跗外侧动脉与第四跖背动脉的外径、走行、吻合和分布范围。 结果　外踝后动脉跟外侧支为腓动脉的终末支,外径（1.0±0.3）mm。外踝前动脉降支外径（1.3±0.3）mm,沿外踝前缘向下走行,在外踝尖的水平分为前、后支,后支与跟外侧支吻合,占97.9%,吻合处的外径（0.8±0.3）mm;前支与跗外侧动脉吻合,占91.6%,吻合处外径（0.6±0.2）mm;跗外侧动脉发出分支与弓形动脉或第4跖背动脉吻合,占95.8%,吻合处的外径（0.6±0.2）mm。足背外侧皮神经与足背中间皮神经司足背外侧皮肤的感觉。 结论　上述4条动脉吻合形成足背外侧动脉链,扩大了足背外侧皮瓣的切取面积,增加了临床应用的灵活性。     

The lateral calcaneal artery

Summary An anatomic study of the lateral extraosseous and intraosseous arterial supply of the calcaneus and the lateral soft tissue was carried out on 10 fresh lower adult cadaver legs using different anatomic and radiologic procedures (plastination, modified Spalteholz clearing technique, digital subtraction and rotational angiography and computed tomographic angiography). Consistent patterns of extraosseous and intraosseous lateral calcaneal vascular anatomy were demonstrated. The lateral calcaneal artery is a branch of the anterior tibial artery which crosses over the calcaneal tuberosity and forms a large lateral arch with the lateral tarsal artery which is a branch of the dorsalis pedis artery. The intraosseous circulation is supplied laterally by the lateral calcanear artery, medially via the short branches of the lateral plantar artery. Comparing magnet resonance images after fresh calcaneal fractures the lateral calcanear artery may be interrupted by the impacted lateral bulge, by the conventional lateral surgical approach, or by applying a lateral osteosynthesis plate. This may cause avascular bone necrosis. Furthermore the lateral calcanear artery can clinically serve as a vascular pedicle for a local rotational skin flap to cover soft tissue defects of the heel.

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L'artère calcanéenne latérale (ACL)

Résumé L'étude anatomique de la vascularisaiton artérielle extra et intraosseuse du calcanéus et des parties molles a été faite sur 10 jambes fraîches de cadavres d'adultes. Différentes techniques anatomiques et radiologiques ont été utilisées : plastination, diaphanisation (technique de Spaltholtz modifiée), angiographie numérisée par soustraction, angiographie rotationnelle et angiographie par tomographie computérisée. Les aspects habituels de l'anatomie vasculaire de la région latérale du calcanéus ont été décrits : l'ACL est un rameau de l'artère tibiale postérieure ; elle surcroise la tubérosité calcanéenne et constitue une large arcade latérale avec l'artère tarsienne latérale, branche de l'artère dorsale du pied. La moitié de la circulation intraosseuse passe par l'ACL, médialement par des rameaux courts de l'artère plantaire latérale. Lorsqu'on examine les images obtenues en IRM lors de fractures récentes du calcanéus, on constate que l'ACL risque d'être lésée par l'élargissement latéral du calcanéus écrasé. Elle peut l'être aussi lors de l'abord latéral classique de l'os ou lors de l'application d'une plaque d'ostéosynthèse. Le risque en est la nécrose ischémique de l'os. Enfin, l'ACL peut constituer un pédicule vasculaire intéressant pour un lambeau local de rotation, lors de la couverture des pertes de substances cutanées du talon.

     

The lateral calcaneal artery

An anatomic study of the lateral extraosseous and intraosseous arterial supply of the calcaneus and the lateral soft tissue was carried out on 10 fresh lower adult cadaver legs using different anatomic and radiologic procedures (plastination, modified Spalteholz clearing technique, digital subtraction and rotational angiography and computed tomographic angiography). Consistent patterns of extraosseous and intraosseous lateral calcaneal vascular anatomy were demonstrated. The lateral calcaneal artery is a branch of the anterior tibial artery which crosses over the calcaneal tuberosity and forms a large lateral arch with the lateral tarsal artery which is a branch of the dorsalis pedis artery. The intraosseous circulation is supplied laterally by the lateral calcanear artery, medially via the short branches of the lateral plantar artery. Comparing magnet resonance images after fresh calcaneal fractures the lateral calcanear artery may be interrupted by the impacted lateral bulge, by the conventional lateral surgical approach, or by applying a lateral osteosynthesis plate. This may cause avascular bone necrosis. Furthermore the lateral calcanear artery can clinically serve as a vascular pedicle for a local rotational skin flap to cover soft tissue defects of the heel.     

Anatomic basis of a fascio-cutaneous flap supplied by the perforating branch of the peroneal artery

Summary The length, caliber and course of the perforating branch of the peroneal artery are described following examination of both feet of 20 cadavers. This terminal branch of the peroneal artery has a constant, predictable course and may normally be sacrificed without any vascular compromise in the foot. It has great surgical potential at it is strategically situated so that it can act as a vascular pedicle for a large cutaneous flap situated on the lower lateral leg, with an axis of rotation centered at the midtarsal joint. This has been used by the senior author (AC Masquelet) as a pedicle flap and as an island flap for reconstruction of the foot and ankle with satisfying results.

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Bases anatomiques d'un lambeau cutanéo-aponévrotique vascularisé par la branche perforante de l'artère péronière

Résumé La longueur, le calibre et la direction de la branche perforante de l'artère péronière ont été décrites après examen des 2 pieds de 20 cadavres. Cette branche terminale de l'artère péronière a un trajet constant et prévisible. Elle peut être sacrifiée sans risque vasculaire pour le pied. Elle a un grand intérêt chirurgical du fait de sa situation, car elle représente le pédicule vasculaire d'un large lambeau cutané situé sur la face latérale de la partie basse de la jambe avec un axe de rotation centré au milieu de l'articulation du tarse. Ce lambeau a été initialement utilisé par AC Masquelet pour la reconstruction du pied et de la cheville comme lambeau pédiculé et un lambeau en îlot avec des résultats satisfaisants.

     

The lateral calcaneal artery: Anatomic basis for planning safe surgical approaches

The proximity of the lateral calcaneal artery (LCA) to surgical incisions applied to the lateral hindfoot makes it vulnerable to iatrogenic injury and subsequent postoperative skin necrosis. This study aimed to investigate the course of the LCA and to define anatomical points that can be used by surgeons during lateral approaches to the calcaneus. Thirteen leg‐ankle‐foot specimens were dissected and the superficial course of the LCA was outlined by three anatomic points: (a) tip of lateral malleolus, (b) the point where it pierces the deep fascia, and (c) the point where it crosses the line connecting the lateral malleoluswith the insertion of Achilles tendon. Fifteen healthy volunteers were investigated by color Doppler ultrasound where the diameter and depth of LCA were measured. The LCA pierced the deep fascia at a maximum height of 4.5 cm (mean 3.78) above the midpoint of a line extending from the lateral malleolus to the insertion of Achilles tendon. It crossed the previous line at a maximum distance of 3 cm (mean 2.6) posterior to lateral malleolus. At this point, its mean diameter was 1.75 mm on the right and 1.73 mm on the left sides, while its mean depth was 7.73 mm on the right and 8.0 mm on the left sides. A dangerous triangle that contained the superficial course of the artery was mapped out in the lower lateral part of the leg. This triangle should be considered during surgical approaches applied to the lateral hindfoot to avoid damage of the LCA. Clin. Anat. 22:834–839, 2009. © 2009 Wiley‐Liss, Inc.     

Absence of the posterior tibial artery: implications for free transplants of the fibula

Summary A well-documented case of absence of the posterior tibial a. is reported. We have studied 40 personal case-records of dissection of the arteries of the leg in fresh corpses. This study allowed classification of the origins of the leg arteries from the popliteal a. into 7 groups. Several findings emerged: 1) the peroneal a. is constant, for phylogenetic and embryologic reasons, 2) the posterior tibial a. is absent in 1 to 5% of cases [1, 2, 4, 6–8] (Fig. 4), in which case the vascularisation of the fibula remains as normal (the proximal epiphysis of the fibula is vascularised by the anterior tibial a., the diaphysis and the distal epiphysis by the peroneal a.). Other anatomic variations may be found: trifurcation of the popliteal a., origin of the anterior tibial a. from the peroneal a., absence of the anterior tibial a., aplasia of the terminal portions of both the anterior and posterior tibial aa. In practice, absence of the posterior tibial a. can be demonstrated by arteriography and doppler ultrasound. We are dubious about the indications for arteriography, which is not always a risk-free examination, and therefore prefer doppler examination with ultrasound, which supplies adequate information in the majority of cases.

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L'absence d'artère tibiale postérieure: conséquences pratiques sur les transplants libres de la fibula

Réumé Ce travail concerne un cas bien documenté d'absence d'a. tibiale postérieure et une étude analytique de 40 dissections des artères de jambe sur sujets frais. Cette analyse a permis de classifier l'origine des artères de jambe à partir de l'a. poplitée en 7 groupes. Plusieurs déductions ont été faites : l'a. fibulaire est constante pour des raisons phylogèniques et embryologiques; l'a. tibiale postérieure est absente dans l à 5 % des cas [1, 2, 4, 6–8] (Fig. 4), et dans ce cas la vascularisation de la fibula demeure inchangée (l'épiphyse proximale de la fibula est vascularisée par l'a. tibiale antérieure, la diaphyse et l'épiphyse distale sont vascularisées par l'a. fibulaire). D'autres variations anatomiques peuvent se rencontrer : trifurcation de l'a. poplitée ; origine de l'a. tibiale antérieure à partir de l'a. fibulaire ; absence d'a. tibiale antérieure ; aplasie de la partie terminale des deux aa. tibiales antérieure et postérieure. En pratique, l'absence d'a. tibiale postérieure peut être affirmée par l'artériographie et l'échographie doppler. L'indication de l'artériographie qui n'est pas un examen anodin doit être nuancée, les auteurs préfèrent pour cette raison le doppler avec échographie doppler qui apporte des éléments suffisants dans la majorité des cas.

     

跟外侧神经与神经源性跟痛症关系的解剖学基础

目的　探讨跟外侧神经的局部解剖特点及其与神经源性跟痛症的关系,为临床诊断治疗提供解剖学依据。 方法　32侧防腐成人尸体下肢标本,解剖观察跟外侧神经的起源、分支、走行和分布特点。 结果　跟外侧神经均起自于腓肠神经,9.38%以单干的形式出现,28.13%为双干,43.75%为3干,18.75%为4干。神经分布于足跟外侧及跟底外侧1/3的皮肤和跟垫组织以及骨膜。 结论　跟外侧神经在跟管内和覆盖于小趾展肌表面的足底腱膜外侧部的锐利缘处均有可能被卡压而引发神经源性跟痛症。     

踝足部血管吻合支的研究与吻合胫前或胫后动脉逆行皮瓣的设计

目的：研究胫前动脉、胫后动脉和腓动脉之间在足踝部的吻合支的粗细,为吻合胫前或胫后动脉远端逆行血供皮瓣设计提供解剖学基础。方法：46侧新鲜小腿的动脉灌注红色塑料,制成动脉铸型标本。观察胫前、胫后和腓动脉在踝足部的吻合支的形态,测量血管的内径。结果：胫前、胫后和腓动脉三者之间在足踝部的吻合支丰富,胫后动脉经足底弓、足底深支与胫前动脉的吻合支最粗,内径为2.3mm。结论：胫前、胫后和腓动脉三者之间在足踝部的吻合支丰富,胫前动脉或胫后动脉之一断裂或栓塞时,只要三者之间在踝足部的主要吻合支未遭受破坏,胫前动脉或胫后动脉远端仍可作为皮瓣受区血管被利用。     

Structure of the Achilles tendon at the insertion on the calcaneal tuberosity

Findings on the twisting structure and insertional location of the AT on the calcaneal tuberosity are inconsistent. Therefore, to obtain a better understanding of the mechanisms underlying insertional Achilles tendinopathy, clarification of the anatomy of the twisting structure and location of the AT insertion onto the calcaneal tuberosity is important. The purpose of this study was to reveal the twisted structure of the AT and the location of its insertion onto the calcaneal tuberosity using Japanese cadavers. The study was conducted using 132 legs from 74 cadavers (mean age at death, 78.3 ± 11.1 years; 87 sides from men, 45 from women). Only soleus (Sol) attached to the deep layer of the calcaneal tuberosity was classified as least twist (Type I), both the lateral head of the gastrocnemius (LG) and Sol attached to the deep layer of the calcaneal tuberosity were classified as moderate twist (Type II), and only LG attached to the deep layer of the calcaneal tuberosity was classified as extreme twist (Type III). The Achilles tendon insertion onto the calcaneal tuberosity was classified as a superior, middle or inferior facet. Twist structure was Type I (least) in 31 legs (24%), Type II (moderate) in 87 legs (67%), and Type III (extreme) in 12 legs (9%). A comparison between males and females revealed that among men, 20 legs (24%) were Type I, 57 legs (67%) Type II, and eight legs (9%) Type III. Among women, 11 legs (24%) were Type I, 30 legs (67%) Type II, and four legs (9%) Type III. No significant differences were apparent between sexes. The fascicles of the Achilles tendon attach mainly in the middle facet. Anterior fibers of the Achilles tendon, where insertional Achilles tendinopathy is most likely, are Sol in Type I, LG and Sol in Type II, and LG only in Type III. This suggests the possibility that a different strain is produced in the anterior fibers of the Achilles tendon (calcaneal side) where insertional Achilles tendinopathy is most likely to occur in each type. We look forward to elucidating the mechanisms generating insertional Achilles tendinopathy in future biomedical studies based on the present results.     

Branching patterns of the popliteal artery and its clinical importance

Purpose  The aim of this study was to evaluate the popliteal artery branching patterns and related measurements. Methods  A cadaveric study in forty lower limbs was performed to improve the understanding of anatomy of the popliteal artery and its main branches. Results  Normal branching of the popliteal artery was present in 36 specimens (90%). High origin of the anterior tibial artery was seen in two specimens (5%). The bifurcation was at the level of proximal border of popliteus, but the posterior tibial artery originated directly from the popliteal artery in one specimen (2.5%). Trifurcation pattern with no trunk was observed in one specimen (2.5%). Conclusions  We believe that a review of the anatomic characteristics of the popliteal artery and its branches will be beneficial for the surgical approaches and the choice of suitable arterial graft sites. This study was presented at 9th Congress of European Association of Clinical Anatomy in Prague, 5–8 September 2007.